10 Questions: Robert Spiera, MD

What's the biggest barrier to your practicing medicine today? Time pressure, says Robert F. Spiera, MD. That's his short answer to just one of the 10 Questions the MedPage Today staff is asking leading clinicians and researchers to get their personal views on their chosen profession. Below are his responses to the rest of those questions.

Spiera is director of the Scleroderma and Vasculitis Center at the Hospital for Special Surgery and professor of clinical medicine at Weill Cornell Medical College in New York City. He obtained his medical degree from Yale University and did his residency at New York Presbyterian Hospital/Weill Cornell Medical Center.

1. What's the biggest barrier to your practicing medicine today?

There are many barriers to the practice of medicine today, although it remains an amazingly rewarding profession. One important barrier is time pressure. Many physicians, including myself, are overextended, with patient care and academic responsibilities (both of which we enjoy, and are the essence of why we chose our profession), but, unfortunately, we also have copious administrative and regulatory responsibilities consuming our time. Even some of the self-imposed regulations such as re-credentialing are time consuming and redundant, given the many continuing medical education activities in which we are engaged. It seems that every individual regulatory body asserts the ability to infringe on our time, often in ways that do nothing to enhance our knowledge or improve our practice. The evolution (or more correctly, devolution) of medical records has similarly been a major barrier to practicing medicine. Medical records initially were intended as a means of communicating between physicians and within a physician's office -- a way to understand our thought processes and capture information relevant to making optimal medical decisions for the patient. Now medical records have become largely about billing, particularly in medical specialties. This is likely to become even worse in the era of ICD-10, which, if implemented, will be a regulatory monster that could ultimately necessitate that a major focus of physician activities will be coding responsibilities, and these are already excessive. As a secondary consultant, I often encounter enormously lengthy electronic medical records recapturing data not at all relevant to the patient visit, but clearly retained there largely in part for billing reasons. Ultimately, it becomes difficult to extract the meaningful essence of the physician-patient interaction from such a note. Hopefully, this is a process in evolution and the pendulum will swing away from this billing focus to a format designed to best capture the information provided and the thought process of each visit. Electronic medical records hold the promise of increasing efficiency, improving communication, and ultimately thereby improving care, but at the present time those goals don't seem to be the primary focus of the way records are constructed.

2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds, tests, etc.) and how did you respond?

I have many vivid memories of patients who had difficulty affording to pay for healthcare. A most pointed story was a young woman who had a fairly high-level job and struggled with systemic lupus. She lost her job and was left without health insurance at a time when she was going through a flare of lupus-related renal disease. We had limited ability to control the cost of her laboratory testing but the commercial labs worked with her on this. We saw her for some time as charity care, minimizing the burden of her visits with us. Unfortunately, she became quite ill requiring hospitalization. She was fortunate to have a local hospital in her home state (she was not local to us) offer her charity care, which allowed for two hospitalizations, and ongoing follow-up in a clinic setting, although her access to the subspecialists we would have liked to have seen involved in her care was limited. Ultimately, she did reasonably well, but things could have been much smoother had there not been this gap in her coverage.

3. What do you most often wish you could say to patients, but don't?

There is not much that I wish to say to patients that I do not, recognizing that a physician-patient relationship is a very personal one and honesty is essential for success in that relationship as in any other. At times, however, I am confronted with a patient wanting to focus on unproven naturopathic remedies, usually out of desperation when I am offering them imperfect options (generally medications with many potential side effects and less-than-perfect efficacy), and they are grasping at alternatives that promise relief with no potential side effects. Often these conversations arise in the context of a visit in which major medical decisions need to be made, and I am hoping to focus on what is truly known or not known about an intervention in an evidence-based way. If I cut the conversation regarding unproven alternative remedies short, however, particularly with a new patient, it often leads to mistrust or a sense that I am not a sufficiently broad-thinking physician. This is not the case, and I try to make it clear that any intervention would be welcome if shown to be safe and effective in some sort of methodical way. Generally, once I have established a relationship with a patient this type of conversation is much easier, but I often have to bite my tongue and hold back earlier in the course of therapy and spend the time indulging these conversations without the likelihood of any tangible benefit beyond helping create that trusting, positive relationship with the patient. This, however, cannot be underestimated in its importance.

4. If you could change or eliminate something about the healthcare system, what would it be?

ICD-10. In general, the linking of billing to "documented" captured information at the time of service is demeaning and counterproductive. I find it embarrassing at times reading notes documenting the number of minutes a physician spent with a patient, assuming that for a complex problem an adequate amount of time would be spent. I honestly believe this system will ultimately be abandoned, as physicians hoping to "game" the system could do so even more easily than in traditional billing systems. Ultimately, as patients receive access to their records and recognize that unimportant information has become the focus of their records, I think they will facilitate this system being abandoned.

5. What is the most important piece of advice for med students or doctors just starting out today?

Identify what you love doing. Be cautious about selecting a specialty based on lifestyle or compensation, as those can change overnight. Also, treat every interaction with every patient with respect, recognizing that no matter how minor the problem may seem to you at that moment, it is of sufficient importance to the patient that they are spending their time and resources to see you for that. Finally, taking the time to listen to the patient's story or "narrative" of the interaction often is the key towards understanding the entire interaction and making the appropriate diagnosis.

6. What is your "elevator" pitch to persuade someone to pursue a career in medicine?

Physicians for the most part are happy with our day-to-day activities. We are in a constantly intellectually stimulating environment. We have bad days and good days, but for the most part never question whether our days are spent in a worthwhile manner. At times, medicine can be absolutely uplifting. Physicians will always make a living and have the privilege of making a living doing what we love and having the reward of caring for people at their most fragile hour.

7. What is the most rewarding aspect of being a doctor?

There is no single most rewarding aspect of being a doctor. Rather, the combination of daily intimate personal interactions with patients combined with the intellectual context of an evolving science where on a yearly, if not monthly basis insights are recognized that translate into progress in the care of those patients truly forms the basis of a rewarding vocation.

8. What is the most memorable research published since you became a physician and why?

The most memorable research published since I became a physician was the initial publication of clinical trials of TNF inhibitors (infliximab and etanercept) in the treatment of rheumatoid arthritis. In the prior decade, numerous insights into disease pathogenesis had seemed promising, but many did not translate into the development of clinically effective interventions. Those publications in the late 90s reporting results of well done, double blinded, placebo-controlled trials demonstrating these new "biologics" to be effective in rheumatoid arthritis was exciting and indeed transforming of our specialty. In the ensuing nearly 2 decades, many other such biologics have been developed for the treatment of rheumatoid arthritis, lupus, and with the demonstration of the efficacy of rituximab in ANCA-associated vasculitis, the promise of our science leading to better therapies has been realized. It seems we are on the precipice of many more dramatic breakthroughs in the coming decades.

9. Do you have a favorite hospital-based TV show?

I do not really watch many hospital-based television shows, but years ago I watched "ER." I am a rheumatologist, and it was always amusing to me that for the glamour of Hollywood our diseases when featured on the show became surgical emergencies, which are certainly dramatic, whereas in reality our specialty generally involves conditions that are medically treated.

10. What is your advice to other physicians on how to avoid burnout?

In order to avoid burnout, I suggest maintaining involvement in ongoing educational activities and attending national and regional meetings to interact with colleagues. Ours is an exciting career, where science combines with the art of medicine to make us better at our craft. Also, in a very practical way, spend some time each week thinking about the remarkable patients we meet and how they manage to juggle their often life-threatening or disabling conditions with dignity. Physicians have a tendency to be whiny, and although in this era of increasing corporate medicine perhaps we have a right to be, our struggles pale in comparison to what our patients are confronting every day.

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